introduction to 10 minute cbt -...
TRANSCRIPT
Introduction to 10 Minute CBT
Dr Lee David
GP, CBT Specialist
Evidence for CBT – Mental health
Strong evidence for benefits of CBT in mental health conditions: e.g. depression, anxiety disorders, panic attacks, health anxiety, OCD
CBT as effective as antidepressants for moderate to severe depression with reduced rate of long-term relapse
NICE guidelines promote CBT for depression and anxiety / panic disorder
Higher rates of depression and anxiety in people with chronic physical disease and can worsen health outcomes
Physical health conditions and CBT
Depression and anxiety disorders common in patients with chronic physical health problems (e.g. CHD, diabetes, COPD)
Untreated mental health conditions associated with worse physical outcomes Cardiovascular patients with depression have higher mortality rates Depression in diabetes associated with worse glycaemic control, more
complications and lower medication adherence
Low mood poor motivation leads to reduced active self-management
Poorer adherence to treatment plans or self-care activities such as smoking cessation or dietary changes
Depression increases adverse health behaviours such as physical inactivity
CBT shown to be effective for managing both anxiety and depression in a range of physical health conditions
What is 10 Minute CBT?
Not possible to condense a standard CBT session into only 10 minutes
But we can bring bite size CBT principles into 10-20 consultations within GPs’ existing working practice
Extremely flexible approach - can be used in many different settings
Realistic, practical skills which build on your existing repertoire of communication skills
A new ‘ tool’ to add to your ‘toolkit’
Aims of 10 Minute CBT Help people to make sense of their difficulties
They may see things from different perspective or look at the bigger picture (helicopter view)
Make links between different aspects of their experience such as thoughts and behaviour
Use a CBT framework and collaborative partnership to facilitate development of self management skills
Patient identifies themselves what changes might be helpful in their lives
Cognitive-Behavioural (5-areas) Model
Bio-psycho-social holistic approach to understanding experiences
Formulation of problems using a CBT model shown to have therapeutic outcome in CBT
How people think in a specific situation will affect how they feel emotionally and physically
It will also alter their behaviour, often creating a vicious cycle that only worsens their problems
Our internal reactions are not simply related to events but to the meaning we attach to a particular event
THOUGHTS
FEELINGS BEHAVIOUR
PHYSICAL SYMPTOMS
ENVIRONMENTAL FACTORS
The 5-areas or Cognitive-Behavioural Model (CBM)
Defining ‘Thoughts’
Words and visual images that pass through people’s minds
Includes attitudes, ideas, expectations, memories, beliefs and images
Represent evaluations of our world (i.e. how we make sense of our experience)
Identifying feelings Refers to emotional experiences
Clusters of negative feelings: sadness, anxiety, anger
Thoughts are in the mind; feelings are also experienced in the body
NB - In English language, people often use the word ‘feel’ to describe a thought or belief
Is ‘feeling worthless’ a thought or a feeling? Why?
Thoughts and feelings are linked The same event will have different emotional
consequences depending on the interpretation
Therefore, to understand people’s distress, we must first understand their thoughts
Empathic statements:
“I can understand why you might be feeling so low if you are having the thought that you are a failure....”
Changing unhelpful thoughts One aim of (standard) CBT is to identify and change any
negative or unhelpful thoughts
Thoughts are viewed as opinions open to investigation and evaluation rather than facts
BUT – this process is unrealistic for a 10 minute GP consultation
Highlighting and labelling (rather than arguing with) unhelpful thoughts can be more helpful in brief consultations
“So, you are having the thought that....”
“That thought seems to make you feel really sad...”
“Is this your ‘depression thinking’ showing up again...?”
The key role of behaviour
What we do (behaviour) can also affect how we think and feel
Some behaviours designed to ‘cope’ with problems may actually have a key role in maintaining them by creating a vicious cycle
Behaviour change is a highly effective strategy for changing difficult thoughts and emotions
Case example: Exploring different reactions to the same situation
Moira has a chronic low back problem
and has given up work due to persistent pain.
How might she react to this life experience?
Different thoughts cause differing feelings and behaviour….1
Thoughts My life is ruined by this pain. I’m a worthless person because I can’t work. What’s the point in living?
Feelings
Physical symptoms
Behaviour
Different thoughts cause differing feelings and behaviour….
Thoughts My life is ruined by this pain. I’m a worthless person because I can’t work. What’s the point in living?
Feelings Sad / low / depressed
Physical symptoms
Pain worsens. Lethargy, tiredness. Biological symptoms of depression
Behaviour Stop self-caring. Reduce activity levels, excessive resting. Withdraw from others.
Different thoughts cause differing feelings and behaviour….2
Thoughts What if something even worse happens? What if this pain means the cancer is coming back? The pain could become even more unbearable.
Feelings
Physical symptoms
Behaviour
Different thoughts cause differing feelings and behaviour….2
Thoughts What if something even worse happens? What if this pain means the cancer is coming back? The pain could become even more unbearable.
Feelings Anxious, panicky
Physical symptoms
Shaky, sweaty, racing heart. Other anxiety-related symptoms
Behaviour Try not to think about the worst, Avoid reminders of illness, Excessive reassurance seeking
Different thoughts cause differing feelings and behaviour….3
Thoughts This is wrong! It’s not fair. I shouldn’t feel this way! The doctors should be doing more to help me!
Feelings
Physical symptoms
Behaviour
Different thoughts cause differing feelings and behaviour….3
Thoughts This is wrong! It’s not fair. I shouldn’t feel this way! The doctors should be doing more to help me!
Feelings Angry, bitter, resentful
Physical symptoms
Physical tension (may worsen pain), Difficulty sleeping
Behaviour Aggression towards family and medical professionals
10 Minute CBT Communication Skills 1. Set an agenda / write a problem list (effective use of
time) Prioritize the use of time and improves collaboration
2. Choose a recent, typical and specific example Who? What? Where? When? What happened? Use the patient’s own words: Last Friday morning when I
accidently broke a coffee cup, I started to feel very low and tearful....
3. Explore the problem using the 5 areas of the CBM
Explore the example using the CBM: Useful questions
Thoughts What was going through your mind?
Did you have any images? What did you say to yourself?
What’s the most difficult thing about this? What’s the worst that might happen?
Feelings How did you feel emotionally?
How did that thought make you feel? You seem quite [sad] when you say that...?
Behaviour What did you do when...?
How do you usually react in that situation? Is there anything you are avoiding now? What would you do differently if you felt
better?
Physical symptoms Which physical symptoms did you notice?
How is this affecting you physically? Which symptoms bother you most? What was happening in your body?
Background / environmental factors What else is going on in your life that could be affecting how you feel?
Are there demands at home? Are there financial difficulties? Do you have someone you can talk to about the problem?
Are there difficulties at work? Are you unable to work / unemployed?
10 Minute CBT Communication Skills (2)
4. Summarize and highlight links / vicious cycles Help patients to reflect on their problems from a new perspective
Highlight links between different aspects of problems and any vicious cycles
5. Use a ‘handover’ question to encourage collaboration Self-enablement: patient reflects and take responsibility for self
This may occur at home after the consultation (cliff-hanger!)
What do you make of all this? What can you take away from our discussion today? What might you say to a friend in the same situation? How might this help you cope with your problems differently in future?
10 Minute CBT Communication Skills (3)
5. Use empowering explanations (psychoeducation) Promote greater understanding and how to cope with specific difficulties
E.g.: role of tiredness in depression; vicious cycles in anxiety
Interactive dialogue and questions to encourage collaboration; avoid jargon
6. Jointly plan relevant homework tasks (goal setting) Completing homework predicts outcome of CBT
Enables patient to generalise what they have learned into daily life
Tasks should be simple and realistic (‘confidence ruler’)
Set as a ‘no-lose’ experiment
Always remember to review homework tasks
7. Ask for feedback and check patient understanding Particularly important in health anxiety
Video example: Using the 5-areas / CBM Chart
Thoughts Feelings
Behaviour (Helpful and unhelpful)
Physical Symptoms
Environmental factors
Cognitive-behavioural model of depression
Cognitive factors / Thoughts
Negative thoughts: self-criticism, negative view of the world Hopelessness, Low motivation Negative cognitive bias (focus on and remember the bad)
Emotions / Feelings
Sadness, low mood Loss of enjoyment Anxiety, guilt, shame, anger
Behavioural factors
Cut down enjoyable and meaningful activities, avoid social interaction Reduce self-care Excessive rest (increases lethargy) Other unhelpful activities e.g. alcohol / drugs, self-harm, reassurance-seeking (worsen self-esteem)
Physical Symptoms
Low energy and tiredness; Poor concentration and memory Disturbed sleep, changes in appetite and weight, loss of libido Pain / other physical symptoms
Unhelpful behaviour in depression
Depressed people typically behave in ways that maintain depression and low self-esteem as a vicious cycle e.g.: Avoid friends – don’t answer the door or phone
Avoid dealing with problems – don’t open the post
Don’t go to work or put off looking for a job
Excessive rest or sleep during the day; spend the day staring at unfulfilling daytime TV
Cut out exercise and reduce self-care; comfort eat crisps and chocolates
Behavioural activation (BA) BA is a brief structured treatment for depression
Aim is to increase enjoyable and meaningful activities
Behaving ‘as if’ we feel (a little bit) better leads to Increased rewarding life experiences
Reduced lethargy
Improved mood
Using behavioural activation Informal BA – simply encourage increased enjoyable
and meaningful activities
Use values to encourage and motivate: What do you care about? Who and what is most important
in your life?
What small steps can you take in the direction of this value?
Formal BA uses an activity monitoring diary
Start by identifying baseline levels of activity and gradually begin to plan additional activities
Activity monitoring diary
Activities (give details)
Importance (rate 1-10)
Enjoyment (rate 1-10)
6-7 am
7-8 am
8-9 am
9-10 am
10-11 am
11-12 noon
12-1pm
1-2pm
Planning activities Choice of tasks should be agreed jointly and largely
come from the patient
Focus on moving in the direction of core values (‘Who and what matters to you in life?’)
Try to balance enjoyable and meaningful activities
Confidence ruler: How confident are you that you will be able to carry this out (rate from 1-10)? <7 – consider revising or breaking goal into smaller steps
Setting realistic expectations for improvement Change should be broken down into manageable
steps Start small and build up: e.g. I will start with a 5-10
minute walk Ask the patient what the next small step towards a
bigger target would look like
Now 1 2 3 4 5 Your goal
Examples of activities Exercise – e.g. Walking, swimming
Social interaction – meeting or phoning friends
Making a start on important projects (set a short time e.g. 5 minutes or a simple task)
Self-care activities (e.g. tidy house, pay bills)
Enjoyable activities – re-starting hobbies or developing new interests
NB – for patients with long-term conditions, activities may not be identical or at the same level as prior to the illness but can still be meaningful and rewarding
Cognitive-behavioural model of anxiety
Cognitive factors / Thoughts
Catastrophic thinking, focus on extreme negative outcomes Rumination, preoccupation with negative future outcomes
Emotions / Feelings
Anxiety, panic, worry, fear Secondary depression
Behavioural factors
Avoidance, ‘escape’ from perceived dangerous situations Safety behaviours (e.g. overuse of medication, resting / avoiding exercise or activities, staying with other people) Body checking
Physical Symptoms
Adrenaline-based fear response (racing heart, palpitations, SOB, chest pain, shaking, sweating, chest tightness, choking sensation, numbness, tingling, gastro etc) Other symptoms of existing physical disease
Brief strategies for anxiety in primary care
Provide credible and effective explanations of feared physical symptoms
Learning to tolerate uncertainty
Behavioural strategies: reduced avoidance (graded exposure); moving in valued life directions
Simple mindfulness exercises (e.g. free apps such as Insight Timer): tolerate distressing thoughts and feelings
‘Worry time’ in generalised anxiety
Minimize ‘as required’ prescriptions which may increase vicious cycles of anxiety over time
Contact details
www.10minutecbt.co.uk
Using CBT in General Practice: The 10 Minute CBT Handbook (Scion Publishing,2013)